Even once they’ve reached the age of full-term babies, preemies continue to need some special care. As you prepare to take your baby home, keep these tips in mind:
Read the month-by-month chapters in this book. They apply to your preterm baby as well as to full-termers. But remember to adjust for your baby’s corrected age.
Keep your home warmer than usual, about 72°F or so, for the first few weeks that your baby is at home. The temperature regulating mechanism is usually functioning in premature
infants by the time they go home, but because of their small size and greater skin surface in relation to fat, they may have difficulty keeping comfortable without a little help. In
addition, having to expend a great many calories to keep warm could interfere with weight gain. If your baby seems unusually fussy, check the room temperature to see if it’s warm enough. Feel baby’s arms, legs, or the nape of the neck to be sure it isn’t too cool in the room. (However, don’t overheat the room.)
Buy diapers made for preemies, if necessary. You can also buy baby clothes in preemie sizes, but don’t buy too many—before you know it, your baby will have outgrown them.
Sterilize bottles, if you’re giving them, by boiling them before the first use and running them through a hot dishwasher after each feeding. Though it may be an unnecessary precaution for a term baby, it’s a good one to take for preemies, who are more susceptible to infection.
Continue for a few months, or until baby’s doctor gives you the okay to pack away the sterilizer.
Feed your baby frequently, even though this may mean spending most of your time nursing or bottle feeding. Preemies have very small stomachs, and they may need to fill them up as
often as every two hours. They also may not be able to suckle as efficiently or effectively as full-termers, and so they may take longer—as long as an hour—to drink their fill. Don’t rush feedings.
Ask the doctor if your baby should be receiving a baby multivitamin supplement. Preterm babies can be at greater risk of becoming vitamin deficient than full-termers and may need this extra insurance.
Don’t start solids until your doctor gives the go-ahead. Generally, solids are introduced to a preterm infant when weight reaches 13 to 15 pounds, when more than 32 ounces of formula is consumed daily for at least a week, and/or when the corrected age is six months.
Occasionally, when a baby is not satisfied with just formula or breast milk, solids may be started as early as four months, corrected age.
Relax. Without a doubt, your baby has been through a lot—and so have you. But once he or she is home, and once you’ve taken the above precautions, try to put the experience behind both of you. As great as the impulse may be to hover or overprotect, aim instead to treat your baby like the normal, healthy child he or she is now.
What It’s Important to Know: HEALTH PROBLEMS COMMON IN LOW- BIRTHWEIGHT BABIES
Prematurity is risky business. Tiny bodies are not fully mature, many systems (heat regulatory, respiratory, and digestive, for example) aren’t yet fully operative, and not surprisingly, the risk of neonatal illness is increased. As the technology for keeping such babies alive improves, more
attention is being given to these common preemie conditions, and completely successful treatment is becoming more and more the norm for many of them. (New treatments are being developed almost daily and so may not be detailed here, so be sure to ask your neonatologist or pediatrician about recent advances.) The medical problems that most frequently complicate the lives of preterm infants include:
Respiratory distress syndrome (RDS). Because of immaturity, the premature lung often lacks pulmonary surfactant, a detergent-like substance that helps keep the air sacs (alveoli) in the lungs from collapsing. Without surfactant the tiny air sacs collapse like deflating balloons with each expiration, forcing the tiny baby to work harder and harder to breathe. Babies who have undergone severe stress in the uterus, usually during labor and delivery, are less likely to lack surfactant, as the stress appears to speed lung maturation.
RDS, the most common lung disease of premature infants, was once frequently fatal, but more than 80 percent of babies who develop RDS today survive, thanks to an increased understanding of the syndrome and new ways of treatment. Extra oxygen is given via a plastic oxygen hood, or via continuous positive airway pressure (CPAP), which is administered through tubes that fit into the nostrils of the nose or mouth. The continuous pressure keeps the lungs from collapsing until the body
begins producing sufficient surfactant, usually in three to five days. For babies with severe RDS, a breathing tube is placed and the baby put on a respirator. Surfactant is then administered directly to the baby’s lungs via the breathing tube. Sometimes, when lung immaturity is detected in utero, RDS can be prevented entirely by the prenatal administration of a hormone to the mother, to speed lung maturation and production of surfactant.
A mild case of RDS usually lasts for the first week of life, though if the baby is placed on a respirator, the recovery may be much slower. Babies with severe cases of RDS may be at an
increased risk of colds or respiratory illnesses during their first two years of life, a greater likelihood of childhood wheezing or asthmalike illnesses, and a greater likelihood of being hospitalized in their first two years.
Bronchopulmonary dysplasia (BPD). In some babies, particularly those born very small, long-term oxygen administration and mechanical ventilation appear to combine with lung immaturity to cause BPD, or chronic lung disease. The condition, which results from lung injury, is usually diagnosed when a newborn still requires increased oxygen after reaching 36 weeks’ gestation. Specific lung changes are generally seen on X rays, and these babies frequently gain weight slowly and are subject to apnea. Treatment of BPD includes extra oxygen; continued mechanical ventilation; medications such as bronchodilators (to help open the airways) or steroids (to reduce inflammation); limiting fluids or giving diuretics (to reduce excess fluid, which can worsen breathing); RSV and influenza vaccinations. A few babies continue to require oxygen when they go home, and all require a high caloric intake to improve growth. Often the condition is outgrown as the lungs mature, though babies with BPD may be at increased risk for respiratory infections.
Apnea of prematurity. Though apnea, periods of breathing cessation, can occur in any newborn, this problem is much more common among premature infants. Apnea of prematurity occurs when
preemies’ immature respiratory and nervous systems cause them to stop breathing for short periods. It is diagnosed when a baby has such periods that last more than 20 seconds or that are shorter but are associated with bradycardia, a slowing of the heart rate. It is also considered apnea if the cessation of breathing is associated with the baby’s color changing to pale, purplish, or blue. Almost all babies born at 30 weeks or less will experience apnea.
Apnea is treated by stimulating the infant to start rebreathing by rubbing or patting the baby’s skin, administering medication (such as caffeine or theophylline), or by using continuous positive airway pressure (CPAP), in which oxygen is delivered under pressure through little tubes into the baby’s nose. Many babies will outgrow apnea by the time they reach 36 weeks’ gestation. Occasionally, monitoring at home may be required, though most babies no longer show signs of apnea by the time they are ten weeks past their due date. Apnea of prematurity is not associated with SIDS. If a baby has breathing pauses after apnea goes away, it is not considered apnea of prematurity and is more likely due to some other problem.
Patent ductus arteriosus. While baby is still in the uterus, there is a duct connecting the aorta (the artery through which blood from the heart is sent to the rest of the body) and the left pulmonary artery (the one leading to the lungs) called the ductus arteriosus. This duct shunts blood away from the
nonfunctioning lungs and is kept open during gestation by high levels of prostaglandin E (one of a group of fatty acids produced by the body) in the blood. Normally, levels of prostaglandin E fall at delivery, and the duct begins to close within a few hours. But in about half of very small premature
babies (those weighing 3 pounds, 5 ounces), and in some larger babies, levels of prostaglandin E don’t drop and the duct remains open or “patent.” In many cases there are no symptoms, except a heart murmer and a little shortness of breath on exertion and/or blueness of the lips, and the duct closes by itself sooner after birth. Occasionally, however, severe complications occur. Treatment with an antiprostaglandin drug (indomethacin) is often successful in closing the duct; when it isn’t, surgery generally does the job.
Retinopathy of prematurity (ROP). This condition, caused by abnormal growth of the blood vessels in an infant’s eye, affects 85 percent of babies born earlier than 28 weeks. Though babies born between 28 and 34 weeks are also at risk (though not at such a high percentage), typically only the smallest premies, no matter what their gestational age, have the highest risk. It was once thought to be caused by excessive oxygen administration, but it is now known that a high level of oxygen is only one of the factors involved, and doctors are still trying to determine what other factors might
contribute to ROP. Close monitoring of blood gases in the infant when oxygen therapy is given is now routine and does seem to help minimize the risk of ROP.
Since ROP can lead to scarring and distortion of the retina, increased risk of nearsightedness (myopia), wandering eye (amblyopia), involuntary rhythmic movements of the eye (nystagmus), and even blindness, a newborn with ROP will need to be seen by a pediatric ophthalmologist. Infants with severe ROP may require treatment to stop the progression of the abnormal vessels. With
treatment, the inner lining of the eye at the ends of these vessels is killed to prevent further abnormal growth of the blood vessels.
Intraventricular hemorrhage (IVH). IVH, or bleeding in the brain, is extremely common among premature infants because the vessels in their developing brains are very fragile and can bleed easily.
Intraventricular hemorrhage strikes 15 to 20 percent of preemies weighing less than 3 pounds, 5 ounces, most often within the first 72 hours of life. The most severe hemorrhages (which strike only 5 to 10 percent of extremely premature babies) require close observation to correct any further
problems that develop—for example, hydrocephalus (blockage of spinal fluid). Regular follow-up ultrasounds are usually ordered for such hemorrhages until they are resolved. Babies with the more severe-grade hemorrhages are also at greater risk for seizures immediately, and handicaps later on.
There is no specific treatment for IVH. Surgery will not prevent or cure the bleeding. In mild cases (and most cases are), the blood is absorbed by the body. Usually the follow-up head ultrasound is normal and the baby’s development is normal for a preterm baby.
Necrotizing enterocolitis (NEC). NEC is an inflammation of the intestines that doesn’t occur until feedings have begun. The cause is unknown, but because the more premature a baby is, the greater the risk of NEC, doctors speculate that the intestines of very premature babies are not developed enough to completely handle digestion. Babies fed breast milk get NEC less often than babies fed formula.
The symptoms of this serious bowel disease include abdominal distension, bilious vomiting, apnea, and blood in the stool. A baby with necrotizing enterocolitis is usually put on intravenous feedings and antibiotics. If there is serious deterioration of the intestine, surgery is usually performed to remove the damaged portion.
Anemia. Many premature infants develop anemia (too few red blood cells) because their red blood cells (like all babies’) have a shorter life than red blood cells of adults (this may be exaggerated if
the baby’s blood type is different from the mother’s), they make few new red blood cells in the first few weeks of life (like all infants), and the frequent blood samples that must be taken from the baby to do necessary laboratory tests make it difficult for red blood cells to replenish. Mild anemia may not need treatment if the number of red blood cells is enough to carry oxygen to meet the baby’s needs.
Severe anemia is usually treated by giving the baby a blood transfusion. Since preemies, whether they’re anemic or not, are born with low levels of iron, they are usually given iron supplements to help them build up the reserves necessary to produce red blood cells.
Infection. Premature infants are most vulnerable to a variety of infections because they are born before the transfer of disease-fighting antibodies from the mother that normally occurs toward the end of pregnancy. Preemies also have an immature immune system, making it more difficult to fight germs, including those that are introduced via feeding tubes, IV lines, and blood tests. Among the infections preemies are more likely to come down with are pneumonia, urinary tract infections, sepsis (infection of the body or bloodstream), and meningitis. Babies whose blood, urine, or spinal fluid cultures come back positive for signs of infection are treated with a full course of IV antibiotics.